Informed Consent for Psychotherapy

General Information The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding of how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you as well as to help you clarify what it is that you want for yourself.

Consent is a valuable part of our work. If you do not understand or are uncomfortable with the questions or content brought up in the therapeutic process, please use your right to let me know any time (before, during, or after) our work together. We will talk through the ways you can express this request verbally and non-verbally throughout therapy.

Confidentiality The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons through a signed Release of Information. Limitations of such client held privilege of confidentiality exist and are itemized below:

If a client threatens or attempts to commit suicide or otherwise conducts themself in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if the information is obtained for the purpose of rendering an expert’s report to an attorney.

-Occasionally I may need to confidentially consult with other professionals in their areas of expertise in order to provide the best treatment for you. This includes clinical supervision and consultation as a process for certification with the American Association of Sexuality Educators, Counselors and Therapists.

-If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Relationship Therapy Clients ONLY: In the Relationship Clinic, we operate with limited confidentiality. I will assume that anything you bring up with me individually is permissible to be brought into therapy unless you explicitly request that it remain private between us (where limitations 1-7 above do not otherwise apply).

Fees

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your services. If you choose to use Out of Network rates with your insurance, we encourage you to call your insurance provider and find out what your deductible and co-pay/co-insurance is for mental health services. Your health insurance may cover all or part of the fees; you will have access to a super bill on the client portal that you may submit to your insurance company for potential reimbursement. However, you are ultimately responsible for all fees incurred. Each client is responsible for payment for services at the beginning of each session.

Please note that billing will be facilitated through STRIPE, a web-based, HIPAA-compliant billing company.

Payment for sessions will occur at time of service (debit, credit, FSA or HSA cards).

*If there has been 12 or more months since the last scheduled appointment, it is considered a new episode of care and will require a revised intake session. ** -**We charge $250 per hour for other professional services you may need, though we will break down the hourly cost if we work for periods of less than one hour. Other services include telephone or SMS conversations lasting longer than 5 minutes, consultation services, and the time spent performing any other service you may request of us. If you become involved in legal proceedings that require our participation, you will be expected to pay for all of our professional time ($400 per hour), including preparation and transportation costs and time, even if we are called to testify by another party.

-Payment for services is due at the time of service. And your receipt is available on this client portal

-You should also be aware that your contract with your health insurance company and use of your FSA/HSA/HRA card requires that if you choose to submit the paperwork to them for potential reimbursement or payment for services, you authorize us to include on your invoice information relevant to the services that we provide to you. This invoice requires a clinical diagnosis. Sometimes, we will be requested to provide additional clinical information such as treatment plans, summaries, or copies of your entire Clinical Record. This may require additional authorization. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files.

About your therapist

As an interpersonal and culturally sensitive mental health therapist, my approach begins with us building a strong relationship that is based on trust, respect, and honesty. From there, we will work to replace shame, fear, and low self-esteem with self-acceptance, compassion, and a sense of personal worth and value. Our intention is for you to leave our sessions feeling validated, accepted, and challenged to face your struggles with new insights and increased confidence. My style is active, meaning that I balance listening and empathic support with gentle challenges, exercises, and ideas for maintaining your therapeutic growth outside of our regular sessions. In fact, at Wellness Lab & Clinics, we believe that much of your growth happens outside of the therapy session, so I will work to equip you with the tools and strategies you need to live life in a more present and authentic way. Some of the techniques I often use include mindfulness and relaxation exercises, communication skills, journal and letter writing, creative/artistic forms of expression, and humor.

Therapy should be a collaborative process. I will check in with you periodically about how our work is going, but I also encourage you to let me know if something is not working for you. I welcome any and all feedback about the counseling process.

Complaints

If you feel dissatisfied with our work together, I encourage you to talk about it with me in therapy. I will do my best to listen to your point of view and will try to resolve your concerns. If you feel that I have not responded in a satisfactory manner, you can also bring a complaint against me by contacting the appropriate licensing agency:

Cathi C. Stegall, Ph.D, LCSW, CST (License # L6635)

State of Oregon, Board of Licensed Social Workers

Attention: COMPLIANCE DIVISION

3218 Pringle Road S., Suite #240

Salem, OR 97302-6310

(503) 378-5735

You may also contact my fellow colleague and contracted care provider, Dr. Sandy Newsome at (541) 371.5547 x1 for complaints or concerns.

Client Consent to Treatment

I, the client (or his or her parent or guardian), have read and understand this agreement. I consent to counseling and paying for professional services under the terms described above with Cathi Stegall and understand that I have the right to revoke this Consent to Treatment in writing and terminate therapy at any time I desire (however, please note that your provider may need to contact you for billing purposes following the formal date of your decision to revoke this Consent).

Practice Policies